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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202767
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:20:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2020 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20200731144515
FACILITY NAME:LIGHTHOUSE VILLA RCFFACILITY NUMBER:
435202767
ADMINISTRATOR:OGLE, FREDFACILITY TYPE:
735
ADDRESS:215 OMIRA DRTELEPHONE:
(408) 772-1220
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 4DATE:
06/13/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Fred OgleTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff is not properly clothed during work shifts.
Medications are not properly stored.
Staff did not administer medication to resident.
INVESTIGATION FINDINGS:
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On 6/13/2023, LPAs Monter and Patel conducted an unannounced complaint investigation of the above allegations and met with Administrator, Fred Ogle.

Staff are not properly clothed during work shifts.

Based on an interview with Administrator (ADM), Administrator stated this did not occur. LPA’s interviewed residents R1 through R4 on a previous visit, 5/10/23 and residents stated they have never seen ADM walk around the facility dress inappropriately. On 6/13/23 LPA’s re-interviewed residents R1-R3 regarding the allegation above. R4 was not interviewed because they are visiting their parents. Residents R1-R3 stated they have not seen the ADM dress inappropriately or in his underwear.

Page 1 out of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20200731144515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LIGHTHOUSE VILLA RCF
FACILITY NUMBER: 435202767
VISIT DATE: 06/13/2023
NARRATIVE
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Medications are not properly stored.

During a complaint investigation on 5/10/2023 LPA’s observed the facility’s locked medication cabinet. LPAs did not observe any medications improperly stored or scattered. LPA’s interviewed residents R1 through R4 regarding the allegation above. residents stated they have never seen medications scattered on the table or medications not being properly stored.

On 6/13/2023, LPA’s observed the facility’s medication cabinet. LPAs did not observe any medications improperly stored or scattered. LPA’s interviewed residents R1-R3 asking if they have ever seen medications improperly stored or scattered. Residents R1-R3 stated they have not seen medications scattered or improperly stored.

Staff did not administer medication to residents.

During a complaint investigation on 5/10/2023 LPA’s observed the facility’s medication log. LPA’s observed that medications have been given when cross referencing to bubble pack and other medications. LPA’s interviewed residents R1 thorough R4, residents stated they have always gotten their medication and administrator has never forgotten.

On 06/13/2023, LPA’s observed the facility’s medication log. LPA’s observed that medications have been given when cross referencing to bubble pack and other medications. LPA’s interviewed residents R1 thorough R3, residents stated they have always gotten their medication and administrator has never forgotten.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Administrator, Fred Ogle and a copy of the report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2020 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20200731144515

FACILITY NAME:LIGHTHOUSE VILLA RCFFACILITY NUMBER:
435202767
ADMINISTRATOR:OGLE, FREDFACILITY TYPE:
735
ADDRESS:215 OMIRA DRTELEPHONE:
(408) 772-1220
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 4DATE:
06/13/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Fred OgleTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff smoking inside of facility.
INVESTIGATION FINDINGS:
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On 6/13/2023, LPAs Monter and Patel conducted an unannounced complaint investigation of the above allegations and met with Administrator, Fred Ogle.

Staff smokes inside the facility.

During a previous investigation on 5/10/23 LPA's interviewed administrator (ADM) regarding smoking in the facility. ADM stated he smokes in the designated smoking area. ADM stated the designated smoking areas are outside, the backyard and in the garage.

Page 1 out of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200731144515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LIGHTHOUSE VILLA RCF
FACILITY NUMBER: 435202767
VISIT DATE: 06/13/2023
NARRATIVE
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According to San Jose Code of Ordinances, it states "Designated smoking area" means such portion of an outdoor common area that has been designated for smoking by the person with legal control over the common area and which complies with all of the following:
A. The area is unenclosed.
B. The area is located at least thirty feet from any operable doorway, window opening or other vent into an enclosed area.
C. The perimeter of the area is clearly demarcated.
D. Signs indicate that the area is designated for smoking.
Based on the facility’s House rules; the smoking area are permitted in “designated areas only.” Based on an interview with ADM, the designated smoking area is in the garage, outside and backyard. LPA photographed pictures of ashtrays and cigarettes in the garage. Note: the garage is directly connected to the facility’s kitchen.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
LPA informed ADM if they require an extension for more time then they would need to inform LPA with the section cited and the reason why they require more time.

This report was reviewed with Administrator Fred Ogle and a copy of the report was provided. Appeal Rights was provided.

Page 2 out of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20200731144515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LIGHTHOUSE VILLA RCF
FACILITY NUMBER: 435202767
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2023
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights-(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
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Admininstrator/Licensee will submit a written plan to ensure the safety of the residents. Administrator will provide LPA with new house rules regarding smoking that protects the health, safety and personal rights of residents in care.
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Based on observation & interview, the licensee did not comply with the section cited above in the facility's garage. ADM stated he smokes in the garage, which is directly connected to kitchen, which poses an potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5